RN Case Manager

Beloit Health System is looking to add an RN Case Manager to our Care Coordination Team!

Shift: 1st
Schedule: 8 a.m.

- 4:30 p.m.
Hours per week: 40
Benefits Status: Eligible
Department: Care Coordination

• The RN Case Manager (CM) will complete utilization review responsibilities and assist with coordinating the patient transition of care from admission to discharge.
• Assist with assessing the physical, functional, social, psychological, environmental, learning and financial needs of the patient as appropriate.
• Identify problems, goals and interventions to meet the patient’s needs.
• Provide appropriate interventions that demonstrate knowledge of and sensitivity toward cultural diversity and religious, developmental, health literacy, and educational backgrounds of the population served.
• Evaluate patient’s progress toward discharge goal, including identification and evaluation of barriers to meeting or complying with the plan of care.
• Participate in multi-disciplinary discharge rounds and care conferences to ensure appropriate and timely discharge of patients; effectively communicate to the comprehensive care team the level of care needed based on medical necessity using hospital approved guidelines.
• Provide education, information, direction, and support related to patient care goals and discharge plan.
• Identify patients at risk for readmission and work with the care team to ensure patient needs and follow-up care is in place to minimize the potential for readmission. Work with the transition of care nurse to follow high risk patients 30 days post discharge.
• Act as a patient advocate and assist with problem solving and addressing any barriers to care or compliance with care plan.
• Coordinate care and treatment plans between providers.
• Facilitate communication between providers and departments as necessary to ensure timely care and cost-effective utilization of resources.
• Determine appropriate admission status (inpatient, observation, outpatient in a bed) using hospital approved guidelines.
• Conduct concurrent reviews of admissions/observations for monitoring medical necessity for hospital stay using hospital approved guidelines.
• Discuss with physicians any concerns regarding utilization of services, level of care, medical necessity, LOS, and documentation requirements.
• Consult physician advisor (Director of Hospitalists and department heads) regarding admissions that do not meet hospital approved guidelines/criteria and the admitting or attending physician disagrees.
• Complete initial and continued stay insurance reviews as requested by payers for certification of coverage.
• Manage denials related to lack of medical necessity as determined by the payer, including setting up peer-to-peer review and written appeals.
• Identify quality issues and report to leadership of quality department.
• Participate in prospective, concurrent and retrospective case reviews as requested.
• Use hospital approved guidelines to educate physicians and nursing staff on optimal care for hospital admissions and readmissions.
• Maintain accurate patient records and patient confidentiality; documentation meets requirements for audits and QI report needs.
• Identify patient complaints/issues and direct appropriately (knowledgeable of HCAHPS survey questions).
• Attend mandatory training sessions and staff meetings as assigned.
• Develop, implement, and evaluate department initiatives and goals as assigned.
• Assist with the collection, analysis, benchmarking and reporting of data.
• Collaborate in the development of policies, protocols, and guidelines for the case management program.
• Promote the case management program to care providers.

• Current Wisconsin RN license.
• Minimum of 2 years acute care hospital experience.
• Excellent observation, organizational, verbal and written communication skills.
• Ability to solve problems quickly while under time constraints.
  
  Ability to be flexible with schedule to manage case load efficiently and effectively.
• CPR certification within 90 days.
• Adheres to established Health System and Care Coordination department policies, rules and regulations.
• Maintains ethical conduct and keeps confidential personal and medical information about patients.
• Relationship:
  Report to Director and Manager of Quality, Risk and Care Coordination.
• Provides clinical direction to social workers.